NURSING CARE PLAN

Submitted To: Submitted By:

Ms Kamini Manisha Joshi
Asst. Prof. ACN MSc. Nursing 1st
Semester
Identification data
Name of the patient -Mrs Xyz
W/O – Mr xyz
Age- 28 years
Ward-Labour room
Education - graduate
Occupation – house wife
Duration of marriage – 2 years
Date of admission – 25/12/2020
Chief complaints on admission – amenorrhoea from 9
months. Having labour pain since morning, back ache.
Present medical history – patient having severe labour pain.
Past medical history – no history of DM, HTN,CAD and
T.B.
Present surgical history – not having any present surgical
history.
Past surgical history – not having any past surgical history.
Family history – in patient family having mother in-law,
father in-law, her husband or her brother in-law. In patient
family having no history of genetically disorders.
Personal history – patient is vegetarian. No history of drug
allergic or drug addiction. No use of any type of substances
use like smoking, drug abused and alcohol etc.
Functional history – sleep pattern and appetite is normal.
 Family tree

Mother in law (40

Father in law (42 years)
years)

Husband (30 years) Brother in-law (24years)

Patient (28 years)

Obstetrical history:
Patient get married in 2019, patient having no any previous
obstetrical history, no history of abortion, still birth or ivf
treatment.
Menstrual history:
Patient menstrual history is normal, patient age of menarche is
13 years, menstrual cycle is normal with appropriate flow
with 5 days duration.
Assessment of patient on admission:
General
Body built – moderate
Weight – 56kg
Anaemia – no
Pallor – no
Heart – NAD
Lungs – NAD
Liver - NAD
Head to toe examination with postnatal examination:
Head – scalp is clear, proper hair distribution, no any node
present in patient head.
Face – face is pale colour, pigmentation present.
Eyes – eyes are normal in symmetry, vision is adequate, not
having pain or any discharge.
Ears – ears are normal in shape and size, hearing proper, no
discharge present.
Nose – no runny nose, sense of smell, normal in shape.
Mouth – teats are present, tongue is clean, no odour present.
Neck – no tenderness in neck, no any nodes present, no pain,
Brest – inspect redness or engorgement, nipple should be soft,
pliable, intact and everted , assess painful bleeding, bruised,
blistered, cracked nipple.
Abdominal:
On examination fundal height – below the xyphisternum.
On auscultation – F.H.S. 148/min
On palpation through GRIP :
Fundal grip – softer consistency
Lateral grip – in left lateral grip felt like a continuous hard,
Surface.
Pelvic grip – heard round part felt it means presenting part is
head.
Pauli grip – head is flexed.
Uterine contraction – 2contraction/10min, duration>20 second
Vaginal examination:
Vulva – normal
Vagina – normal
Cervix – dilation 2cm
Membrane – intact
Presenting part – head
Pelvis – seems adequate
Vital signs and general health:
Pulse rate, respiratory rate, body temperature, any outward
odour, skin condition and the women overall color and
complexion.
Patient vital signs on admission are:
BP- 130/90,Pulse rate- 78b/mt.
Temperature -36.4°Crespiratory rate – 20b/mt
Investigation:
S.No Investigations Patient’s Normal values
. values
1 Sodium 139mEq/lit 135-145mEq/lit
2 Potassium 3.93mEq/lit 3.5-6.3mEq/lit
3 CBC
RBC 5.12mil/cum 4.3-
HB m 6.3mil/cumm
PVC 8.9gm/dl 12-14gm/dl
PLATELET COUNT 36.4% 40-50%
BLOOD GROUP 4.43lakh/ml 1.4-4.41lakh/ml
B+ve
4 Blood glucose 90mg/dl 80-120mg/dl
5 Serum cholesterol 242mg/dl 120-250mg/dl
LDL 167mg/dl <155
HDL 33mg/dl <33
6 SGOT 219U/L 0-40U/L
SGPT 67U/L 5-36U/L

Urine examination:
Albumin: Nil
Sugar: Nil
RBC: Nil
WBC: Nil

Nursing diagnosis:
Impaired gas exchanges related to altered oxygen supply.
Altered progress of labour related to physiological
process.
Potential for injury related to physical, chemical and
external factors.
Potential for infection related to invasive procedures,
rupture of amniotic membrane.
Anxiety related to situational crisis
Pain related to physical and psychological factors.
 NURSING CARE PLAN

Nursing Nursing Nursing intervention Evaluation Evaluation

diagnosis objectives outcome
Impaired gas Foetal  Locate the foetal Foetal Foetal
exchanges hypoxia heart by heart hypoxia
related to will be determine foetal sound is will be
altered prevented. position and recorded relieved.
oxygen presentation. every 30
supply.  Auscultate foetal minutes
heart rate throughout
through foetal active
back. stage of
 Count and labour.
record the foetal
heart rate half an
hourly in active
phase and every
15 minute
during second
phase.
 Provide the left
lateral position
to relieve
pressure on
inferior vena
cava and
improve uterine
blood flow.
Nursing Nursing Nursing Evaluation Evaluation
diagnosis objective intervention outcome
s
Altered Labour  Record the  Uterine Labour
progress of will frequency contraction will
labour progress. and duration is assessed progress
related to of every half an within
physiologica contraction hourly for time.
l process. every half an 10 minute
hourly and duration
during active of one
phase of contraction.
labour.  Uterine
 Assess and contraction’s
record the  Frequency
cervical and duration
dilatation recorded on
and partograph.
effacement  Recording
every four of cervical
hourly. dialationand
 Assess the effacement
station or every four
descend of hourly.
foetus every
four hourly
and record
and record
on
partograph.
 Assess the
pelvic size
 during PV
examination.

Nursing Nursing Nursing intervention Evaluation Evaluation

diagnosis objectives outcome
Potential Will be  Provide care  History Risk of
for injury protected related to is taken. injury will
related to from injury. admission  Vital be
physical, protocol, take signs are minimized
chemical nursing history, recorded
and note vital sign two
external and laboratory hourly
factors. investigation. in active
 Record stage of
temperature, labour.
pule, B.P. every  Bladder
two hourly. is
 Encourage to emptied
voiding every by K-90
two hourly if catheter.
bladder is  Enema
distended than is given.
empty bladder
by
catheterization.
 Give enema if
ordered by
doctor.
 Discontinue
oxytocin if
indicated and
notify by
doctor. e.g.
foetal distress.
Nursing Nursing Nursing Evaluation Evaluation
diagnosis objectives intervention outcome
Pain related To relieved  Assess pain  Assessed Pain is
to physical pain via the pain relieved.
and verbalizatio level by
psychological n and body body
factors. language. language of
 Assess patient.
coping  Touching
mechanism therapy,
verbal and effleurage,
non verbal  And back
expression massage is
of fear. given.
 Use  Reinforce
touching for
therapy- breathing
stroking, and
holding relaxation
hand, technique.
effleurage,  Left lateral
massage of position is
back. given.
 Teach or
reinforce
breathing
and
relaxation
techniques.
 Provide
confortable
position.
Nursing Nursing Nursing Evaluation Evaluation
diagnosis objectives intervention outcome
Anxiety To reduce  Orient to  Patient is Anxiety
related to the anxiety ward the oriented level
situational level. client. about ward reduced.
crises.  Explain all and hospital
the policy.
procedure.  Every
 Explain procedure is
reasons for explained
protocol, e.g. before
restriction of performed.
food and  Attendant
fluid, side or coach is
lying position allowed for
etc. full time.
 Explain about  feeling of
labour patient is
progressing. assessed.
 Encourage
expression of
feeling and
convey
understandin
g and
acceptance.
 Do not
women leave
alone.
HEALTH EDUCATION :
 Explain all procedure, seek permission for examination
and carrying out procedures and discuss the findings with
the women.
 Keep the women informed about the progress of labour.
 Praise the women, encourage her and reassure her that
things are going well.
 Ensure the respect and privacy of the women during
examination and discussion.
 Encourage the women to bath or clean herself and her
genitals at the onset of labour.
 Ensure cleanliness of birthing area.
 Encourage the women to empty her bladder frequently.
 The women should be allowed to remain mobile during
labour especially the first stage.
 The women should be free to choose any position she
desires and feels comfortable in during labour and
delivery.
 Women who are not at risk of requiring general
anaesthesia can have light, easily digested low fat food
during labour.